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|
Attributes | |
ACN | 518680 |
Time | |
Date | 200107 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : vhhh.airport |
State Reference | FO |
Altitude | msl single value : 4500 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-500 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : tunna 3 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 12800 flight time type : 2500 |
ASRS Report | 518680 |
Events | |
Anomaly | non adherence : published procedure non adherence : far non adherence : clearance non adherence : company policies other spatial deviation other spatial deviation |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We started a turn to a 180 degree heading prior to prawn, contrary to the SID procedure. After takeoff, I went 'heads down' momentarily to check the selected frequency because I didn't get a response to my call up to departure control. At the same time, the PF initiated a turn to 180 degrees prior to passing the prawn waypoint. Apparently, he misinterped the map display because he failed to recognize that the selected range was 20 NM vice 10 NM and he made the turn based on the aircraft symbol (triangle) approaching the waypoint. Fatigue and workload were contributing factors. This was a night departure, following a 14 hour ground time. The previous day we flew 2 legs, 10 hours flight time, with a 14 hour duty day. Workload was increased by the runway changes prior to departure and minimal navigation database. Initially, we planned and 'built' a runway 25L departure. Then we changed to a runway 7R departure due to information from a new ATIS. After engine start, we changed back to a runway 25L departure with WX information updated. These departure procedures had to be built since the navigation database did not include the SID procedures. Given that we had 'briefed' this departure previously, we did not emphasize the turn restr again as we changed the FMC routing and briefed on the taxi out. This was the first leg of a long, 2-LEG flight to maui with a fuel stop in saipan. Departure was delayed due to passenger logistics and we were pushing to stay close to schedule. The WX at the time was reported as few at 1400 ft and scattered at 2200 ft. The terrain south of the runways was visible above the low cloud layer at the time of the turn and the fact that the PF was also using visual references may have contributed to the variance from the SID restr. On initial contact with departure control, the controller advised we were turning south of course and terrain clearance was not assured. Departure control directed a right turn back to runway heading.
Original NASA ASRS Text
Title: A B737-500 CAPT RPTED THAT, AS A RESULT OF FATIGUE AND THE PF'S MISUSE OF THE RANGE RINGS ON THE MAP DISPLAY, THEY MADE A TRACK DEV IN VHHK, FO AIRSPACE.
Narrative: WE STARTED A TURN TO A 180 DEG HDG PRIOR TO PRAWN, CONTRARY TO THE SID PROC. AFTER TKOF, I WENT 'HEADS DOWN' MOMENTARILY TO CHK THE SELECTED FREQ BECAUSE I DIDN'T GET A RESPONSE TO MY CALL UP TO DEP CTL. AT THE SAME TIME, THE PF INITIATED A TURN TO 180 DEGS PRIOR TO PASSING THE PRAWN WAYPOINT. APPARENTLY, HE MISINTERPED THE MAP DISPLAY BECAUSE HE FAILED TO RECOGNIZE THAT THE SELECTED RANGE WAS 20 NM VICE 10 NM AND HE MADE THE TURN BASED ON THE ACFT SYMBOL (TRIANGLE) APCHING THE WAYPOINT. FATIGUE AND WORKLOAD WERE CONTRIBUTING FACTORS. THIS WAS A NIGHT DEP, FOLLOWING A 14 HR GND TIME. THE PREVIOUS DAY WE FLEW 2 LEGS, 10 HRS FLT TIME, WITH A 14 HR DUTY DAY. WORKLOAD WAS INCREASED BY THE RWY CHANGES PRIOR TO DEP AND MINIMAL NAV DATABASE. INITIALLY, WE PLANNED AND 'BUILT' A RWY 25L DEP. THEN WE CHANGED TO A RWY 7R DEP DUE TO INFO FROM A NEW ATIS. AFTER ENG START, WE CHANGED BACK TO A RWY 25L DEP WITH WX INFO UPDATED. THESE DEP PROCS HAD TO BE BUILT SINCE THE NAV DATABASE DID NOT INCLUDE THE SID PROCS. GIVEN THAT WE HAD 'BRIEFED' THIS DEP PREVIOUSLY, WE DID NOT EMPHASIZE THE TURN RESTR AGAIN AS WE CHANGED THE FMC ROUTING AND BRIEFED ON THE TAXI OUT. THIS WAS THE FIRST LEG OF A LONG, 2-LEG FLT TO MAUI WITH A FUEL STOP IN SAIPAN. DEP WAS DELAYED DUE TO PAX LOGISTICS AND WE WERE PUSHING TO STAY CLOSE TO SCHEDULE. THE WX AT THE TIME WAS RPTED AS FEW AT 1400 FT AND SCATTERED AT 2200 FT. THE TERRAIN S OF THE RWYS WAS VISIBLE ABOVE THE LOW CLOUD LAYER AT THE TIME OF THE TURN AND THE FACT THAT THE PF WAS ALSO USING VISUAL REFS MAY HAVE CONTRIBUTED TO THE VARIANCE FROM THE SID RESTR. ON INITIAL CONTACT WITH DEP CTL, THE CTLR ADVISED WE WERE TURNING S OF COURSE AND TERRAIN CLRNC WAS NOT ASSURED. DEP CTL DIRECTED A R TURN BACK TO RWY HEADING.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.